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A nurse is caring for a client.

Exhibits

Complete the following sentence by using the list of options.

The first two actions the nurse should take are

and

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Place the client in a private room (Option 1): Given the positive test results for tuberculosis (TB) exposure, placing the client in a private room is crucial for infection control. This helps prevent the spread of TB, which is a highly contagious disease, to other patients and healthcare staff. Isolation is a standard precaution for patients suspected of having active TB.

Apply supplemental oxygen (Option 2): The client's oxygen saturation is low at 88% on room air, indicating hypoxemia. Administering supplemental oxygen is essential to improve the patient's oxygen levels, ensure adequate tissue perfusion, and address any respiratory distress the patient may be experiencing.


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Related Questions

Correct Answer is B

Explanation

A. Restraint prescriptions typically need to be renewed at least every 24 hours, not every 36 hours, to comply with regulatory standards.

B. Ensuring that two fingers fit under the restraints is essential to confirm that they are not too tight, allowing for circulation and comfort while still securing the client.

C. Checking the client's range of motion should occur more frequently than every 6 hours; ideally, it should be assessed more regularly to prevent complications.

D. Restraints should be secured using a quick-release knot, not a square knot, to ensure they can be removed easily in an emergency.

Correct Answer is A

Explanation

A. Providing finger foods can enhance the client’s ability to feed themselves and may encourage eating, especially for clients with dementia who may have difficulty using utensils or concentrating on traditional meals. This approach promotes independence and can make meals more enjoyable and less stressful.

B. While reducing distractions can be helpful, completely restricting visitors might increase feelings of isolation and may not significantly impact food intake. A supportive social environment can enhance the meal experience.

C. Limiting snacks between meals can decrease overall caloric intake, which is counterproductive for a client at risk for malnutrition. Allowing healthy snacks can help maintain energy levels and supplement nutritional needs.

D. Providing three large meals may overwhelm a client with dementia, as they might struggle with portion sizes and meal structure. Smaller, more frequent meals can be more effective in encouraging intake and ensuring that the client receives adequate nutrition.

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